Adults with a lack of focus could have ADHD

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Paula Driscoll had a hard time sitting still as a kid, doodled a lot, and often wrestled with the feeling that she should be accomplishing more. But she made it through high school and college and became an elementary school teacher. With three small children at home, she did not feel she had trouble managing her life.

But when her youngest child went to school, she found herself with what felt like too much time on her hands. “I couldn’t get anything done,” she said. “I had one room I started to paint, another I was going to reorganize, and I could never complete a task. I couldn’t stay in the house. I went out on one errand after the next.”

Driscoll was 45 when she was diagnosed with attention deficit hyperactivity disorder, or ADHD.

ADHD, a neurobiological disorder that makes it difficult to focus and can also include hyperactivity and impulsivity, has historically been viewed as a childhood disease. Over the last couple decades, research has shown that many of those afflicted carry symptoms into adulthood.

The latest study, led by a Boston Children’s Hospital researcher and published Monday in the journal Pediatrics, suggests that nearly 30 percent of those with childhood ADHD still have the condition as adults ­— often after discontinuing treatment. The researchers followed hundreds of children with ADHD into adulthood and reported that the majority had mental health problems such as alcohol or drug dependence, anxiety, depression, or a personality disorder.

Yet other research suggests that the majority of afflicted adults go undiagnosed. An estimated 4.4 percent of adults in the United States, or more than 8 million people, have adult ADHD, according to government data. Three-quarters aren’t being treated.

“People think: I look like a normal person. People tell me I am smart. I should be able to do well. What is wrong with me?,” said Dr. Craig Surman, an assistant professor of psychiatry at Harvard Medical School and coauthor of the new book “FAST MINDS: How to Thrive If You Have ADHD (Or Think You Might).” “We see a lot of people suffering from depression and anxiety, and when you trace it back, the first thing that cropped up wasADHD.”

Ose Schwab, who founded an ADHD support group in Malden, said there is “a lot of shame and stigma,” in part because of the many myths that surround the disorder. “The worst,” she said, “is that ADHD has something to do with a lack of will or discipline.”

Essentially, ADHD is a problem with the brain’s executive functions that help in control and self-management. The circuitry that underlies the brain’s ability to pay attention is impaired, Surman said.

People do not develop ADHD in adulthood; symptoms must be present in childhood. ADHD is genetic, “more inheritable than asthma or breast cancer,” said “
FAST MINDS” coauthor Dr. Tim Bilkey, a psychiatrist in Ontario who developed a program to help doctors recognize ADHD in adult patients.

The new Pediatrics study suggests that the condition is often chronic and lifelong. Researchers from Boston Children’s Hospital, the Mayo Clinic, and elsewhere assessed 367 young adults in Rochester, Minn., who were diagnosed with ADHD as children and compared them with peers who never had the disorder. Those who had grown up with ADHD were 88 percent more likely to have died, often from accidents or suicides, by the time they reached an average age of 27, compared with the control group. And 57 percent had been diagnosed with a mental health problem compared with 35 percent of the controls.

“It’s really time to stop trivializingADHD as a childhood behavioral problem that’s overtreated,” said study leader Dr. William Barbaresi, director of the Developmental Medicine Center at Children’s Hospital. “It’s a serious health condition that persists” and often, he added, requires regular evaluations and treatment through adulthood.

Doctors first recorded symptoms of the disorder in children in late 18th century Scotland. It went by a variety of names including hyperkinetic disease of infancy and minimal brain dysfunction. It became known as ADD, or attention deficit disorder, in 1980 and was renamed ADHD in 1987.

Much of the problem in both naming and diagnosing the disorder arises because the hyperactivity and impulsivity traits aren’t always present. Girls with ADHD often go undetected because they may be daydreaming, but they aren’t disruptive, Bilkey says.

In adulthood, symptoms evolve. “The hyperactive kid running all around the classroom becomes the restless adult who is always on to the next thing,” Surman says.

Many people might seem to exhibit classic traits of the disorder, but distraction, procrastination, and chronic lateness don’t necessarily mean an adult has ADHD. The symptoms must inhibit the patient in at least two areas of life, such as at work and in a personal relationship, Bilkey says. “And it’s a matter of degree. A lot of people procrastinate about paying their taxes. A patient with ADHD might not file taxes at all.”

The upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is used by doctors to diagnose psychiatric disorders, will relax the criteria for adult ADHD in an effort to make the diagnosis easier, according to Mary V. Solanto, director of the ADHD Center at Mount Sinai Hospital in New York. The revised DSM, due in May, also provides language to help doctors understand how classic childhood ADHD symptoms might look in an adult.

Driscoll, the mother of three, said her doctor was skeptical at first, and dismissive of an online ADHD test she had taken. But after an in-depth psychological test, the doctor prescribed medication.

The Ritalin calmed her down, helped her listen better, improved her memory, and aided her sleep, she said.

Critics of loosening the criteria forADHD worry about escalating use and misuse of stimulants, particularly on college campuses.

Solanto acknowledges that some medical professionals may make an ADHD diagnosis without a thorough inquiry — which she says should involve at least two hours of questioning to establish a history and persistence of symptoms. But, she said, that doesn’t change the data, which repeatedly show that adult ADHD is “abundant and real.”

J. Russell Ramsay is cofounder and codirector of the University of Pennsylvania’s Adult ADHD Treatment and Research program, which helped pioneer cognitive behavioral therapy strategies for ADHD patients. He says that while medication can “unlock barriers,” it doesn’t teach someone how to navigate life.

Young adults with ADHD often have trouble with school, jobs, and relationships, he says, and those who go undiagnosed can “start having negative thoughts about themselves.” Cognitive behavioral therapy helps patients reframe negative thinking to address self-esteem issues and develop strategies for planning and time management.